Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system

Hadush et al. BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-020-02899-8 (2020) 20:206 RESEARCH ARTICLE Open Access Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system Azmach Hadush1*, Ftalew Dagnaw2, Theodros Getachew2, Patricia E. Bailey3, Ruth Lawley4 and Ana Lorena Ruano5 Abstract Background: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. Methods: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. Results: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10–27%) and severe preeclampsia/eclampsia (10–24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7–33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. Conclusion: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities. Keywords: Maternal death, MDSR coverage, Quality of care, Cause of death, Delay factor * Correspondence: 1 World Health Organization, Addis Ababa, Ethiopia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hadush et al. BMC Pregnancy and Childbirth (2020) 20:206 Background Globally, an estimated 303,000 maternal deaths occurred in the year 2015. Of these, 99% came from low and middle-income countries (LMICs), with 66% of them occurring in sub-Saharan Africa [1]. Maternal death surveillance and response (MDSR) was introduced in 2013 as one of the global strategies for ending preventable maternal mortality [2, 3]. MDSR is a continuous surveillance and response cycle that involves the identification, notification, and review of all maternal deaths to provide real time actionable data for the prevention of future similar deaths. In 2015, 76% of LMICs had a national maternal death review committee in place, and 60% had a subnational maternal death review committee [4]. In the same year, most sub-Saharan African countries were implementing MDSR but in a suboptimal manner [4, 5]. Multiple factors can affect the implementation of MDSR. Lack of awareness of the purpose and principles of MDSR among stakeholders, the existence of a blame culture, insufficient number of trained staff to implement MDSR, the unavailability of guidelines and tools, lack of commitment and financial resources all contribute to the implementation of MDSR [4–13]. These barriers may prevent compliance with national and global targets for MDSR and delay the establishment of functioning MDSR committees at all health facilities [14]. Determining the facility level availability of a functional MDSR review committee helps close the knowledge gap about the implementation of MDSR at subnational level. Several studies carried out in Ethiopia have pointed to a changing trend in the distribution of causes of maternal death [15–21]. In 2014 a systematic review revealed that the major causes of maternal death were obstructed labor/uterine rupture (36%), hemorrhage (22%), hypertensive disorders of pregnancy (19%) and sepsis/infection (13%) [22]. A review that looked at maternal deaths from 10 hospitals in Ethiopia showed that 40.3% of maternal deaths had a delay in receiving care after reaching the hospital during delivery [23]. Another facility-based maternal death review from northern Ethiopia indicated that 87.5% of maternal deaths experienced similar delays [16]. Lack of skilled health providers, incorrect diagnosis or mismanagement and shortage of appropriate medical supplies including blood for transfusion were the main reasons for delay [16, 23]. However, almost all of the studies were retrospective, from specific geographic areas of the country, and they were conducted before MDSR was introduced as a national system in 2013. The 2016 Emergency Obstetric and Newborn Care (EmONC) Assessment was a national census of health facilities and included maternal death reviews that were conducted after the national MDSR system was introduced. In this paper the results of MDSR and the EmONC assessment are used to determine the facility Page 2 of 9 level coverage of MDSR implementatio (...truncated)